Robert Fletcher vividly remembers the call that changed his family forever.

It was a May morning four years ago -- just a few hours after his wife, Amanda, had dropped off their infant son for his second day at a new day care. Now Amanda was on the phone, sobbing hysterically, with the news that Blake was dead.

Their child-care provider had placed Blake facedown in a playpen at her home for his nap -- a violation of safety training -- and then had checked him only once or twice over a period of 2 1/2 hours. When medics arrived, the 3-month-old baby had been lifeless for some time.

"His face imprints were left in that playpen,'' Fletcher recalls. "He basically didn't have a chance.''

Blake Fletcher's death devastated his parents and their friends in Park Rapids. It also reveals the serious infant sleep hazards that persist across Minnesota's network of licensed family child-care providers, a system of 11,100 small facilities serving some 91,000 children.

A Star Tribune examination of hundreds of public records shows that the number of children dying in child care has nearly doubled in the past five years -- reaching the rate of one per month. Nearly all the deaths have occurred at in-home providers (also known as family care), and most involved a child sleeping. The newspaper's investigation also found more unsafe-sleep citations, such as lack of training or children in unsafe sleep positions, at in-home settings than at large child-care centers.

The Department of Human Services (DHS), the state's top child-care regulator, is treating the rise in deaths as a public health crisis.

"It's huge," said DHS Inspector General Jerry Kerber. "It makes it clear that something has got to be done. What that something is, I think, is going to take the work. ... It's completely unacceptable."

Using a state licensing website, the Star Tribune reviewed 217 licensed family homes and 185 child-care centers that have been cited since July 2010 for violations of state regulations. Some 20 percent of these family homes were cited for having children in unsafe sleeping positions -- such as sleeping on open beds or in mechanical swings -- or sleeping with heavy blankets that present suffocation hazards. About 12 percent of the child-care centers were cited for such violations.

Large centers were cited more often for unsafe cribs, usually sheets that were too tight or too loose, but the number of workers without required safe-sleep training was much higher at in-home settings.

On Friday, in the wake of the Star Tribune's questions, Kerber issued a statewide memo highlighting the "significant increase" in infant deaths in family child care and the need for providers to follow safe-sleep practices. The memo, which is being sent to all family child-care providers and county regulators, confirmed that many deaths have involved providers who failed to follow safe practices. Kerber also noted cases in which providers gave "misleading information" to investigators and failed to meet training requirements.

A family's dilemma

In handouts to parents, Jacqueline Beavers touted her credentials as a child-care provider: training in CPR and infant safety, even liability insurance to protect the children in her care.

Those assurances quickly came apart for the Fletchers when their son died.

Weeks later, they learned that Beavers had placed Blake on his stomach in a bedroom, even though training requires providers to lay infants on their backs to reduce the risk of death while sleeping. She also failed to check on Blake every 15 minutes -- a best practice taught to providers.

"It's hard to explain the pain you go through," Amanda Fletcher said. "Death is one thing. But your child -- they are not supposed to go."

The trauma from that moment can still feel overwhelming. The lasting grief almost tore apart the Fletchers' marriage. Four years later, Amanda takes antidepressants.

The Fletchers' tragedy started with a dilemma faced by thousands of working parents across Minnesota. Just weeks after Blake was born, in February of that year, Amanda was making plans to return to her $9-an-hour job as a medical records clerk.

"It's kind of the American way," she said. "You have the baby, you stay home with them and then you are back to work to support your family."

So they began looking for child care. They weighed cost, convenience and availability of providers in Park Rapids.

They found that a local child-care center would charge $120 per month more than in-home providers. That's not unusual in Minnesota, where the average annual cost of infant care in a center is $12,900, third-highest in the nation.

At in-home providers, which serve three in five of the Minnesota children in licensed child care, the cost is a more modest $7,350. No other state has such a wide disparity between homes and centers, a financial reality that forces some families to cross centers off their lists.

The Fletchers chose a local in-home provider. But within weeks after Blake started, the woman told them she had too many infants. That sent them searching for a backup. They called as many as 20 providers on the Hubbard County licensing list. All were full. Beavers was the first provider who had an opening for an infant.

When the Fletchers arrived at her home, Beavers showed her credentials, including a document saying she carried liability insurance. Later, after Blake's death, the Fletchers said they learned that her insurance policy had expired months earlier.

"Our son would probably still be here today had she followed the proper guidelines and told us she didn't have insurance," said Robert Fletcher. "He wouldn't have been left there and he wouldn't have been laid facedown in a playpen."

Charges never filed

Beavers, who had operated the facility out of her home since 2003, did not respond to requests for an interview.

Records show she had no prior licensing violations. After Blake's death, the state revoked her license and shut her business down because placing him on his stomach violated safe-sleep guidelines.

Police investigated, but charges were never filed. Initially, the Fletchers say, investigators suspected SIDS. The term, short for sudden infant death syndrome, implies that babies die of unknowable causes.

But as the investigation proceeded, the medical examiner reached a different conclusion. The immediate cause was listed as unknown, but "sleeping facedown in the playpen" was the lone contributing condition, according to the death certificate.

Because Beavers lacked insurance, there was little money to be recouped, and the Fletchers couldn't find an attorney to take their civil case. They feel justice was never served.

Beavers' attorney, John Valen, said the case was "tragic" and that Beavers was distressed and upset by the death, but didn't feel responsible for it. Still, police records show, months later she was waking up in the middle of the night with bad dreams.

"We never believed she was the cause of death of the child," Valen said.

Lone adult

Just because an infant dies does not mean that a provider did something wrong. But Minnesota's child-care case files include some troubling incidents.

Last year, a 2-month-old in Rochester was found facedown on an adult bed and later died; authorities ruled it a case of neglect by the child-care provider. A few months later, a 3-month-old was found facedown at a child-care home in Prior Lake and died at the hospital. Just months after that, a provider in Eagan, who was operating an overcrowded facility, placed a 3-month-old to sleep facedown on a blanket on the floor. When the child was found dead, the provider reportedly tried to mislead investigators.

State officials have begun a review of the deaths and intend to give the Legislature recommendations early next year. About 40 percent of the deaths have resulted in a licensing sanction against the child-care provider.

Leaders in Minnesota's family child-care industry reject any suggestion that the disparity in deaths reflects quality problems unique to licensed in-home facilities.

Katy Chase, executive director of the Minnesota Licensed Family Child Care Association, characterized the rise in deaths as "a very slight increase." She said fewer than 1 percent of providers ever have serious safety problems or deaths.

"No death is allowable," she said. "A death devastates the family, devastates the community, devastates the provider. ... We want to make it better."

Chase said the sheer number of licensed family providers -- more than 11,000 statewide, compared to more than 1,500 licensed centers -- also makes it difficult to establish consistent safety practices. "That's the critical difference," she said.

In addition, she said, family providers are small businesses that operate on tight budgets and have trouble paying for extra training and credentials.

Efforts to increase training and raise standards have been met with resistance by lawmakers and providers. "The problem is a climate of not wanting any more regulation, [of] seeing safety and health education as interfering with the family," Chase said.

The absence of safe-sleep training that inspectors found at in-home settings is particularly troubling, experts say, because there is often only one provider watching children at any given time.

A child's safety largely depends "on the training and the goodwill of the provider," said Beverly Schmalzried, a researcher for Child Care Aware of America. "When the provider isn't aware of the dangers of unsafe sleeping practices, then he or she probably isn't going to follow" best practices.

The public often views unexplained infant deaths as random and "unavoidable" events, said Schmalzried, whose group, based near Washington, D.C., is a national leader in child-care research.

But, she said, many deaths could be prevented if providers were better trained and more diligent in following safe sleeping practices.

Minnesota requires SIDS and safe-sleep training for child-care providers every five years. Sometimes, however, that's not often enough to address new research or changing practices.

A shift in the law

Minnesota has tried for more than a decade to reduce the number of deaths in child-care settings. The record shows setbacks as well as progress.

In 2000, a national study examined sudden infant death syndrome in 11 states; Minnesota stood out with the highest percentage of SIDS deaths occurring in child-care facilities -- fully 40 percent.

Change came quickly. In 2001, the state began requiring all licensed providers to get training in SIDS prevention. The results were dramatic: The number of deaths in child-care settings dropped significantly within a year.

Dr. Rachel Moon, a pediatrician and SIDS researcher at the Children's National Medical Center in Washington, said she is surprised to learn that child-care deaths are on the rise again in Minnesota.

"It's very concerning," said Moon, who conducted the 2000 study. "Minnesota had done this amazing job of training people and getting the word out that babies need to be on their backs. ... They had seen this nice decline in the number of deaths in child care. It makes me wonder: What is going on and why is this?"

One factor may be a change in state safe-sleeping standards enacted by the Legislature five years ago.

In 2001, along with the new training requirement, state regulators started requiring parents to obtain a doctor's note before their providers could place an infant to sleep on his or her stomach.

In 2007, DHS officials tried to get that provision explicitly written into law. When the request reached the Capitol, some lawmakers blasted it as government overreach, saying instead that common sense and parental judgment would do.

"Often times people talk about Minnesota being the nanny state," said Rep. Mary Liz Holberg, R-Lakeville, speaking on the House floor during the 2007 debate. "Here's a perfect example of the nanny state."

The Legislature ultimately passed a bill making it easier to veer from safe-sleeping standards. Instead of a doctor's note, a parent's approval is now all it takes for a licensed provider to place a child on his or her stomach for a nap.

Kathleen Fernbach, director of the Minnesota Sudden Infant Death Center, said the change sent the wrong message. She wonders if it has contributed to the rise in deaths. She also worries that the safe-sleep campaign in Minnesota, which had success at reducing SIDS deaths, has lost momentum.

"The campaign has been going on for nearly 20 years. We all get casual about things,'' she said. "We need to reenergize the campaign."

'Priceless treasures'

Of the six Minnesota children who have died this year in licensed child-care settings, all were at in-home care. Three of the facilities have been temporarily shut down and another was indefinitely closed. In each of the cases, county licensors believed their environments posed "an imminent risk of harm" to children.

In an Anoka County case, an infant died after a provider with a history of violating safe-sleep practices failed to place him to sleep on his back. The cause of death was later determined to be a rare heart condition, but regulators still cited the provider for failing to follow safe-sleep practices. The facility's license remains temporarily suspended.

In a separate case in Scott County, 3-month-old Grant Maloney died after the provider at Kare 'n' 4 Kids swaddled him and placed him down for a nap, police and death records show.

The provider, Karen Patricia Johnson, put Grant down for a nap about 10:30 a.m., propping up his head with a pillow because he had acid reflux, police records show. Over the next half hour, while vacuuming her house, Johnson checked on Grant every 10 or 15 minutes. At about 11 a.m., a sign-language instructor arrived to give a lesson to the older children, and Johnson again checked on Grant, who was still resting on his back.

When Johnson checked him again at 11:30 a.m., she found him on his stomach, with his head against the pillow and his face in the crib. She picked Grant up and found blood coming from his nose. CPR failed to save him. His death was listed as an accident, but the autopsy listed "probable positional asphyxia" as the cause.

Johnson did not return phone calls seeking comment. Her license remains suspended and the county has recommended that her facility be closed.

A parent who turns to Johnson's website today will find it emphasizes peace of mind for parents and her training in CPR and first aid, and a recent nomination as county provider of the year. The closing line of her online biography underscores the stakes at thousands of child-care facilities across Minnesota:

"I know what an honor it is to be entrusted with the safety and well-being of your most priceless treasures -- your children."

Jeremy Olson is a Pulitzer Prize-winning reporter covering health care for the Star Tribune. Trained in investigative and computer-assisted reporting, Olson has covered politics, social services, and family issues.